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Wongtanasarasin W, Nishijima DK, Wood N, DeAngelis J, Storrow A, Schimmel J, Beltre N, Sacco D, Probst MA. Number needed to call in emergency care research: Postenrollment follow-up data from a multicenter prospective syncope study. Acad Emerg Med 2024. [PMID: 39223835 DOI: 10.1111/acem.15010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/08/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Nancy Wood
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - John DeAngelis
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Alan Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Schimmel
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Nataly Beltre
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Dana Sacco
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Marc A Probst
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
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Leafloor CW, McRae AD, Mercier E, Yan JW, Huang P, Mukarram M, Rowe BH, Ishimwe AC, Hegdekar M, Sivilotti MLA, Taljaard M, Nemnom MJ, Thiruganasambandamoorthy V. Utility of serial troponin testing for emergency department patients with syncope. CAN J EMERG MED 2024; 26:535-542. [PMID: 39095575 DOI: 10.1007/s43678-024-00740-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 06/18/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND For emergency department (ED) patients with syncope, cardiac troponin can identify acute coronary syndrome (ACS) and prognosticate for 30-day serious adverse events. However, it is unclear if serial testing improves diagnostic yield and prognostication. METHODS This was a secondary analysis of data from two prospective studies conducted to develop the Canadian Syncope Risk Score. Adults (age ≥ 16 years) with syncope were enrolled, and patient characteristics, vital signs, physician diagnostic impression, electrocardiogram and troponin results, and adjudicated 30-day serious adverse event were collected. The primary outcome was the detection of a serious adverse event within 30 days of ED disposition. The secondary outcome was comparison of ED length of stay among patients with single versus serial troponin measurements. RESULTS 4996 patients [mean age 64.5 (SD 18.8) years, 52.2% male] were included: 4397 (89.8%) with single troponin [232 (5.3%) with serious adverse event in the ED and 203 (4.6%) after ED disposition]; 499 (10.2%) patients with > 1 troponin measurement [39 (7.8%) with serious adverse event in ED and 60 (12.0%) after ED disposition]. Among those with serial measurements, 10 patients (2.0%) had a rise from below to above the 99th percentile threshold, of whom 4 patients (0.8%) suffered serious adverse event: two with arrhythmias diagnosed on electrocardiogram, one with ACS and one suffered respiratory failure. Nine patients (1.8%) had Canadian Syncope Risk Score risk reclassification based on serial measurement, and none suffered 30-day serious adverse event. Median ED length of stay was significantly longer for patients with serial testing (5.6 vs. 3.8 h, p < 0.001). CONCLUSIONS The initial troponin measurement was sufficient for serious adverse event detection and in-ED risk stratification. Serial troponin testing does not improve the diagnostic yield or prognostication and should be reserved for patients with ongoing symptoms or electrocardiogram findings suggestive of cardiac ischemia.
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Affiliation(s)
- Cameron W Leafloor
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, QC, Canada
- CHU de Québec - Université Laval Research Center, Québec City, QC, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, ON, Canada
| | - Paul Huang
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Muhammad Mukarram
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Aline C Ishimwe
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine, and of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
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Sekreter T, Altuncı YA, Uz İ, Akarca FK. Assessing the Predictive Value of Combining Risk Scoring Systems and Ultrasonography for Short-Term Adverse Outcomes in Syncope: A Prospective Observational Study. J Emerg Med 2024; 67:e198-e208. [PMID: 38824037 DOI: 10.1016/j.jemermed.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/03/2024] [Accepted: 03/06/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND In the emergency department (ED), the role of ultrasonography (USG) in risk stratification and predicting adverse events in syncope patients is a current research area. However, it is still unclear how ultrasound can be combined with existing risk scores. OBJECTIVES In this study, it was aimed to examine the contribution of the use of bedside USG to current risk scores in the evaluation of patients presenting to the ED with syncope. The predictive values of the combined use of USG and risk scores for adverse outcomes at 7 and 30 days were examined. METHODS The Canadian Syncope Risk Score (CSRS), San Francisco syncope rules (SFSR), USG findings of carotid and deep venous structures, and echocardiography results were recorded for patients presenting with syncope. Parameters showing significance in the 7-day and 30-day adverse outcome groups were utilized to create new scores termed CSRS-USG and SFSR-USG. Predictive values were evaluated using receiver operating characteristic (ROC) analysis. The difference between the predictive values was evaluated with the DeLong test. RESULTS The study was carried out with 137 participants. Adverse outcomes were observed in 45 participants (32.8%) within 30 days. 32 (71.7%) of the adverse outcomes were in the first 7 days. For 30-day adverse outcomes, the SFSR-USG (p = 0.001) and CSRS-USG (p = 0.038) scores had better predictive accuracy compared to SFSR and CSRS, respectively. However, there was no significant improvement in sensitivity and specificity values. CONCLUSION The use of USG in the evaluation of syncope patients did not result in significant improvement in sensitivity and specificity values for predicting adverse events. However, larger sample-sized studies are needed to understand its potential contributions better.
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Affiliation(s)
- Tarık Sekreter
- Ege University Faculty of Medicine, Department of Emergency Medicine, İzmir, Turkey
| | - Yusuf Ali Altuncı
- Ege University Faculty of Medicine, Department of Emergency Medicine, İzmir, Turkey.
| | - İlhan Uz
- Ege University Faculty of Medicine, Department of Emergency Medicine, İzmir, Turkey
| | - Funda Karbek Akarca
- Ege University Faculty of Medicine, Department of Emergency Medicine, İzmir, Turkey
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Mazzella AJ, Wood BS, Doad J, Hendrickson MJ, Rosman L, Gehi AK. Interhospital variability in hospital admissions for patients with low-risk syncope presenting to the emergency department. Heart Rhythm O2 2024; 5:435-442. [PMID: 39119025 PMCID: PMC11305874 DOI: 10.1016/j.hroo.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
Background Guidelines and risk scores have sought to standardize the management of syncope in the emergency department (ED), but variation in practice remains. Objective The purpose of this study was to explore factors associated with admission for patients presenting to the ED with low-risk syncope. Methods Our study population included adult patients in the Nationwide Emergency Department Sample between 2006 and 2019 who presented to an ED with a primary diagnosis of syncope. Multivariable hierarchical logistic regression analyses determined the association of patient or hospital factors with admission. Reference effect measures methodology assessed the relative contributions of patient, hospital, and unmeasured hospital factors. Results Of the 3,206,739 qualifying encounters during the study period, 804,398 (25.1%) met low-risk criteria. Of these patients, 20,260 were admitted to the hospital (2.5%). Factors associated with increased odds of admission included increasing age and weekend presentation to the hospital, while female sex, lack of medical insurance, hospital region, teaching status, and higher ED volume decile were associated with lower odds of admission. Reference effect measures methodology demonstrated that unmeasured site variability contributed the widest range of odds for admission (odds ratio [OR] 5th percentile vs 95th percentile 0.23-4.38) compared with the composite patient (OR 0.33-3.68) or hospital (OR 0.65-1.30) factors. Conclusion Admission patterns for low-risk syncope varies widely across institutions. Unmeasured site variation contributes significantly to the variability in admission rates, suggesting which hospital a patient presents to plays a disproportionate role in admission decisions. Further guidance to reduce practice variation in syncope care in the ED is needed.
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Affiliation(s)
- Anthony J. Mazzella
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brian S. Wood
- The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Jagroop Doad
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina
| | - Michael J. Hendrickson
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lindsey Rosman
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anil K. Gehi
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Wongtanasarasin W, Nishijima DK, Wood N, DeAngelis J, Storrow A, Schimmel J, Beltre N, Sacco D, Probst MA. Factors associated with incentive redemption among participants in a multicenter prospective syncope clinical study. Acad Emerg Med 2024. [PMID: 38940329 DOI: 10.1111/acem.14979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/15/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Nancy Wood
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - John DeAngelis
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Alan Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Schimmel
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Nataly Beltre
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Dana Sacco
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
| | - Marc A Probst
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York City, New York, USA
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Furlan L, Jacobitti Esposito G, Gianni F, Solbiati M, Mancusi C, Costantino G. Syncope in the Emergency Department: A Practical Approach. J Clin Med 2024; 13:3231. [PMID: 38892942 PMCID: PMC11172976 DOI: 10.3390/jcm13113231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Syncope is a common condition encountered in the emergency department (ED), accounting for about 0.6-3% of all ED visits. Despite its high frequency, a widely accepted management strategy for patients with syncope in the ED is still missing. Since syncope can be the presenting condition of many diseases, both severe and benign, most research efforts have focused on strategies to obtain a definitive etiologic diagnosis. Nevertheless, in everyday clinical practice, a definitive diagnosis is rarely reached after the first evaluation. It is thus troublesome to aid clinicians' reasoning by simply focusing on differential diagnoses. With the current review, we would like to propose a management strategy that guides clinicians both in the identification of conditions that warrant immediate treatment and in the management of patients for whom a diagnosis is not immediately reached, differentiating those that can be safely discharged from those that should be admitted to the hospital or monitored before a final decision. We propose the mnemonic acronym RED-SOS: Recognize syncope; Exclude life-threatening conditions; Diagnose; Stratify the risk of adverse events; Observe; decide on the Setting of care. Based on this acronym, in the different sections of the review, we discuss all the elements that clinicians should consider when assessing patients with syncope.
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Affiliation(s)
- Ludovico Furlan
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Internal Medicine Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giulia Jacobitti Esposito
- Emergency Medicine School, Department of Advanced Biomedical Science, University of Naples Federico II, 80138 Naples, Italy; (G.J.E.); (C.M.)
| | - Francesca Gianni
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Emergency Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Monica Solbiati
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Emergency Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Costantino Mancusi
- Emergency Medicine School, Department of Advanced Biomedical Science, University of Naples Federico II, 80138 Naples, Italy; (G.J.E.); (C.M.)
| | - Giorgio Costantino
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Emergency Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Reed MJ, Karuranga S, Kearns D, Alawiye S, Clarke B, Möckel M, Karamercan M, Janssens K, Riesgo LGC, Torrecilla FM, Golea A, Fernández Cejas JA, Lupan-Muresan EM, Zaimi E, Nuernberger A, Rennét O, Skjaerbaek C, Polyzogopoulou E, Imecz J, Groff P, Camilleri R, Cimpoesu D, Jovic M, Miró Ò, Anderson R, Laribi S. Management of syncope in the Emergency Department: a European prospective cohort study (SEED). Eur J Emerg Med 2024; 31:136-146. [PMID: 38015745 DOI: 10.1097/mej.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND AND IMPORTANCE In 2018, the European Society of Cardiology (ESC) produced syncope guidelines that for the first-time incorporated Emergency Department (ED) management. However, very little is known about the characteristics and management of this patient group across Europe. OBJECTIVES To examine the prevalence, clinical presentation, assessment, investigation (ECG and laboratory testing), management and ESC and Canadian Syncope Risk Score (CSRS) categories of adult European ED patients presenting with transient loss of consciousness (TLOC, undifferentiated or suspected syncope). DESIGN Prospective, multicentre, observational cohort study. SETTINGS AND PARTICIPANTS Adults (≥18 years) presenting to European EDs with TLOC, either undifferentiated or thought to be of syncopal origin. MAIN RESULTS Between 00:01 Monday, September 12th to 23:59 Sunday 25 September 2022, 952 patients presenting to 41 EDs in 14 European countries were enrolled from 98 301 ED presentations (n = 40 sites). Mean age (SD) was 60.7 (21.7) years and 487 participants were male (51.2%). In total, 379 (39.8%) were admitted to hospital and 573 (60.2%) were discharged. 271 (28.5%) were admitted to an observation unit first with 143 (52.8%) of these being admitted from this. 717 (75.3%) participants were high-risk according to ESC guidelines (and not suitable for discharge from ED) and 235 (24.7%) were low risk. Admission rate increased with increasing ESC high-risk factors; 1 ESC high-risk factor; n = 259 (27.2%, admission rate=34.7%), 2; 189 (19.9%; 38.6%), 3; 106 (11.1%, 54.7%, 4; 62 (6.5%, 60.4%), 5; 48 (5.0%, 67.9%, 6+; 53 (5.6%, 67.9%). Furthermore, 660 (69.3%), 250 (26.3%), 34 (3.5%) and 8 (0.8%) participants had a low, medium, high, and very high CSRS respectively with respective admission rates of 31.4%, 56.0%, 76.5% and 75.0%. Admission rates (19.3-88.9%), use of an observation/decision unit (0-100%), and percentage high-risk (64.8-88.9%) varies widely between countries. CONCLUSION This European prospective cohort study reported a 1% prevalence of syncope in the ED. 4 in 10 patients are admitted to hospital although there is wide variation between country in syncope management. Three-quarters of patients have ESC high-risk characteristics with admission percentage rising with increasing ESC high-risk factors.
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Affiliation(s)
- Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Suvi Karuranga
- European Society for Emergency Medicine, Antwerp, Belgium
| | - David Kearns
- University of Edinburgh Medical School, Edinburgh, UK
| | - Salma Alawiye
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh
| | - Ben Clarke
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh
| | - Martin Möckel
- Department of Emergency and Acute Medicine, Campus Mitte and Virchow, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Mehmet Karamercan
- Department of Emergency Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Kelly Janssens
- St Vincents University Healthcare Group, Dublin, Ireland
| | | | | | - Adela Golea
- Emergency Unit, University of Medicine and Pharmacy Cluj, University Emergency County Hospital, Cluj Napoca, Romania
| | | | - Eugenia Maria Lupan-Muresan
- Emergency Medicine Discipline, 'Iuliu Hatieganu' University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - Edmond Zaimi
- University Hospital Centre, Mother Teresa of Tirana, Tirana, Albania
| | | | | | | | | | | | - Paolo Groff
- Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Diana Cimpoesu
- University of Medicine and Pharmacy Grigore T Popa, Iasi, Romania
| | - Miljan Jovic
- General Hospital, Health Centre, Zaječar, Serbia
| | - Òscar Miró
- Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | | | - Said Laribi
- Emergency Medicine Department, CHU Tours, Tours University, Tours, France
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Wu S, Chen Z, Gao Y, Shu S, Chen F, Wu Y, Dai Y, Zhang S, Chen K. Development and Validation of a Novel Predictive Model for the Early Differentiation of Cardiac and Non-Cardiac Syncope. Int J Gen Med 2024; 17:841-853. [PMID: 38463438 PMCID: PMC10924787 DOI: 10.2147/ijgm.s454521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/26/2024] [Indexed: 03/12/2024] Open
Abstract
Background The diagnosis of cardiac syncope remains a challenge. This study sought to develop and validate a diagnostic model for the early identification of individuals likely to have a cardiac cause. Methods 877 syncope patients with a determined cause were retrospectively enrolled at a tertiary heart center. They were randomly divided into the training set and validation set at a 7:3 ratio. We analyzed the demographic information, medical history, laboratory tests, electrocardiogram, and echocardiogram by the least absolute shrinkage and selection operator (LASSO) regression for selection of key features. Then a multivariable logistic regression analysis was performed to identify independent predictors and construct a diagnostic model. The receiver operating characteristic curves, area under the curve (AUC), calibration curves, and decision curve analysis were used to evaluate the predictive accuracy and clinical value of this nomogram. Results Five independent predictors for cardiac syncope were selected: BMI (OR 1.088; 95% CI 1.022-1.158; P =0.008), chest symptoms preceding syncope (OR 5.251; 95% CI 3.326-8.288; P <0.001), logarithmic NT-proBNP (OR 1.463; 95% CI 1.240-1.727; P <0.001), left ventricular ejection fraction (OR 0.940; 95% CI 0.908-0.973; P <0.001), and abnormal electrocardiogram (OR 6.171; 95% CI 3.966-9.600; P <0.001). Subsequently, a nomogram based on a multivariate logistic regression model was developed and validated, yielding AUC of 0.873 (95% CI 0.845-0.902) and 0.856 (95% CI 0.809-0.903), respectively. The calibration curves showcased the nomogram's reasonable calibration, and the decision curve analysis demonstrated good clinical utility. Conclusion A diagnostic tool providing individualized probability predictions for cardiac syncope was developed and validated, which may potentially serve as an effective tool to facilitate early identification of such patients.
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Affiliation(s)
- Sijin Wu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Zhongli Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Gao
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Songren Shu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Feng Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Ying Wu
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Dai
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Shu Zhang
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
| | - Keping Chen
- Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People's Republic of China
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9
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Mu H, Liu J, Huang C, Tang H, Li S, Dong C, Yang T, Liu L, Xu B. Application of five risk stratification tools for syncope in older adults. J Int Med Res 2024; 52:3000605231220894. [PMID: 38190847 PMCID: PMC10775749 DOI: 10.1177/03000605231220894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/24/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVE Treatment of syncope in older adults places a burden on healthcare systems. We used five risk stratification tools to predict short-term adverse outcomes in older patients with syncope. METHODS This was a retrospective analysis of patients with syncope (age ≥60 years) in the emergency department of an urban academic hospital. The data were evaluated using the Risk Stratification of Syncope in the Emergency Department (ROSE), San Francisco Syncope Rule (SFSR), FAINT, Canadian Syncope Risk Score (CSRS), and Boston Syncope Criteria (BSC) tools. Sensitivity, specificity, accuracy, positive and negative predictive value (NPV), and positive and negative likelihood ratios of each tool were calculated and compared for adverse events within 1 month. RESULTS In total, 221 patients (average age 75.6 years) were analyzed. Fifty-nine patients (26.7%) had experienced an adverse event within 1 month. For the ROSE, SFSR, FAINT, CSRS and BSC tools, sensitivities were 81.3%, 76.3%, 93.2%, 71.2%, and 94.9%, specificities were 88.3%, 87.7%, 56.8%, 71.6%, and 67.3%, and NPVs were 92.9%, 91.0%, 95.8%, 87.2%, and 97.3%, respectively. CONCLUSION The five assessed tools could be useful for physicians in screening older patients with syncope for the risk of short-term adverse events, according to the patient's actual situation.
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Affiliation(s)
- Hong Mu
- Department of Emergency, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jiexin Liu
- Department of Neurocardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cheng Huang
- Pingmo Health Center, Daozhen County, Zunyi, Guizhou, China
| | - Hefei Tang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sisi Li
- The Fifth Medical College, Capital Medical University, Beijing, China
| | - Chang Dong
- The Fifth Medical College, Capital Medical University, Beijing, China
| | - Tiecheng Yang
- Department of Emergency, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Limin Liu
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Xu
- Department of Emergency, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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10
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Dipaola F, Gatti M, Menè R, Shiffer D, Giaj Levra A, Solbiati M, Villa P, Costantino G, Furlan R. A Hybrid Model for 30-Day Syncope Prognosis Prediction in the Emergency Department. J Pers Med 2023; 14:4. [PMID: 38276219 PMCID: PMC10817569 DOI: 10.3390/jpm14010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 01/27/2024] Open
Abstract
Syncope is a challenging problem in the emergency department (ED) as the available risk prediction tools have suboptimal predictive performances. Predictive models based on machine learning (ML) are promising tools whose application in the context of syncope remains underexplored. The aim of the present study was to develop and compare the performance of ML-based models in predicting the risk of clinically significant outcomes in patients presenting to the ED for syncope. We enrolled 266 consecutive patients (age 73, IQR 58-83; 52% males) admitted for syncope at three tertiary centers. We collected demographic and clinical information as well as the occurrence of clinically significant outcomes at a 30-day telephone follow-up. We implemented an XGBoost model based on the best-performing candidate predictors. Subsequently, we integrated the XGboost predictors with knowledge-based rules. The obtained hybrid model outperformed the XGboost model (AUC = 0.81 vs. 0.73, p < 0.001) with acceptable calibration. In conclusion, we developed an ML-based model characterized by a commendable capability to predict adverse events within 30 days post-syncope evaluation in the ED. This model relies solely on clinical data routinely collected during a patient's initial syncope evaluation, thus obviating the need for laboratory tests or syncope experienced clinical judgment.
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Affiliation(s)
- Franca Dipaola
- Internal Medicine, Syncope Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy;
| | | | - Roberto Menè
- Department of Medicine and Surgery, University of Milano-Bicocca, 20100 Milan, Italy;
| | - Dana Shiffer
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy;
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy;
| | | | - Monica Solbiati
- Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, 20100 Milan, Italy; (M.S.); (G.C.)
| | - Paolo Villa
- Emergency Medicine Unit, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, 20100 Milan, Italy;
| | - Giorgio Costantino
- Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, 20100 Milan, Italy; (M.S.); (G.C.)
| | - Raffaello Furlan
- Internal Medicine, Syncope Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy;
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy;
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11
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Thiruganasambandamoorthy V, Keller M, Nguyen PAI, Gupta P, Ghaedi B, Cao GZQ, Cheung WJ, Khatiwada B, Nemnom MJ, Yadav K, Eagles D, Brehaut J, Tarhuni W, Rouleau G, Desveaux L, Taljaard M. Implementation of the Canadian syncope pathway: a pilot non-randomized stepped wedge trial. CAN J EMERG MED 2023; 25:808-817. [PMID: 37651075 DOI: 10.1007/s43678-023-00570-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/26/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND We developed the Canadian Syncope Pathway (CSP) based on the Canadian Syncope Risk Score (CSRS) to aid emergency department (ED) syncope management. This pilot implementation study assessed patient inclusion, length of transition period, as well as process measures (engagement, reach, adoption, and fidelity) to prepare for multicenter implementation. METHODS A non-randomized stepped wedge trial at two hospitals was conducted over a 7-month period. After 2-3 months in the control condition, the hospitals crossed over in a stepwise fashion to the intervention condition. Study participants were ED and non-ED physicians, or their delegates, and patients (aged ≥ 18 years) with syncope. We aimed to analyze patient characteristics, ED management including disposition decision, and CSRS recommendations application for all eligible patients during the intervention period. Our targets were 95% inclusion rate, 70% adoption (proportion of physicians who applied the pathway), 60% reach (intervention applied to eligible patients) and 70% fidelity (appropriate recommendations application) for all eligible patients. Clinical Trials registration NCT04790058. RESULTS 1002 eligible patients (mean age 56.6 years; 51.0% males) were included: 349 patients during the control and 653 patients during the intervention period. Physician engagement varied from 39.7% to 97.1% for presentation at meetings. Process measures for the first month and the end of the intervention were: adoption 70.7% (58/82) and 84.4% (103/122), reach 67.5% (108/160) and 55.0% (359/653), fidelity among patients with physician data form completion 86.3% (88/102) and 88.3% (294/333), versus fidelity among all eligible patients 83.8% (134/160) and 83.3% (544/653) respectively with no significant differences in fidelity at one month and the end of the intervention period. CONCLUSION In this pilot study, we achieved all prespecified benchmarks for proceeding to the multicenter CSP implementation except reach. Our results indicate a 1-month transition period will be adequate though regular reminders will be needed during full-scale implementation.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | - Maria Keller
- Emergency Department, Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Phuong Anh Iris Nguyen
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Preeti Gupta
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Bahareh Ghaedi
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - George Z Q Cao
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Warren J Cheung
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Bikalpa Khatiwada
- Emergency Department, Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jamie Brehaut
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
| | - Wadea Tarhuni
- Canadian Cardiac Care, Windsor, ON, Canada
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Genevieve Rouleau
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Université du Québec en Outaouais, St-Jérôme, QB, Canada
| | - Laura Desveaux
- Institute for Better Health & Learning Health System Program Lead, Trillium Health Partners, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Monica Taljaard
- The Ottawa Hospital Research Institute, Clinical Epidemiology Unit, The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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12
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Balen F, Boumaza N, Mouret C, Roncalli J, Charpentier S, Dubucs X. Performance of high-sensitivity cardiac troponin T in predicting major cardiovascular events in patients admitted to the emergency department for syncope with normal ECG: An observational prospective study. Arch Cardiovasc Dis 2023; 116:447-452. [PMID: 37640627 DOI: 10.1016/j.acvd.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/08/2023] [Accepted: 07/19/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION History of syncope, clinical examination and electrocardiographic (ECG) findings are fundamental to assess the risk of major cardiovascular events (MACE) in patients attending the emergency department (ED) for syncope. However, in the absence of abnormal clinical examination findings or an abnormal ECG in the ED, transient rhythm or conduction disorders may not be safely excluded, hence predicting MACE remains challenging. High-sensitivity cardiac troponin T (hs-cTnT) may be a useful tool in this context. AIM The primary objective was to evaluate the performance of hs-cTnT in the diagnosis of MACE at 30 days in patients attending the ED for syncope with a normal initial ECG. METHODS This was a prospective observational cohort study that took place in the ED of a French university hospital between June 2018 and June 2019. Patients≥18 years admitted to the ED for syncope with a normal ECG were eligible. After receiving verbal consent from patients, the ED physician collected clinical and ECG data and all patients had a blood sample taken that included hs-cTnT measurement. The primary outcome was MACE within 30 days after the ED visit. MACE were evaluated by consulting the patient's medical records and telephoning patients or their general practitioners. Sensitivity, specificity, positive and negative predictive values were calculated with their 95% confidence intervals (CI) for different hs-cTnT thresholds. RESULTS Data from 246 patients were analysed, including 21 (9%) with MACE. Hs-cTnT had an area under the curve of 0.917 (CI: 0.872-0.962). Hs-cTnT with a threshold of 19ng/L had a sensitivity of 86% (CI: 64-97) and a specificity of 86% (CI: 81-90) for predicting MACE. CONCLUSION Hs-cTnT may be a relevant tool for assessing MACE risk in patients with syncope and normal ECG results.
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Affiliation(s)
- Frederic Balen
- Emergency Department, University Hospital of Toulouse, 31059 Toulouse, France; Centre for Epidemiology and Population Health Research (CERPOP), Inserm UMR 1027, Toulouse, France.
| | - Nicolas Boumaza
- Emergency Department, University Hospital of Toulouse, 31059 Toulouse, France
| | - Cyrille Mouret
- Emergency Department, University Hospital of Toulouse, 31059 Toulouse, France
| | - Jerome Roncalli
- Cardiology Department, CARDIOMET Institute, University Hospital of Toulouse, 31059 Toulouse, France; Toulouse III - Paul-Sabatier University, 31330 Toulouse, France
| | - Sandrine Charpentier
- Emergency Department, University Hospital of Toulouse, 31059 Toulouse, France; Centre for Epidemiology and Population Health Research (CERPOP), Inserm UMR 1027, Toulouse, France; Toulouse III - Paul-Sabatier University, 31330 Toulouse, France
| | - Xavier Dubucs
- Emergency Department, University Hospital of Toulouse, 31059 Toulouse, France; Centre for Epidemiology and Population Health Research (CERPOP), Inserm UMR 1027, Toulouse, France; Toulouse III - Paul-Sabatier University, 31330 Toulouse, France
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Uit Het Broek LG, Ort BBA, Vermeulen H, Pelgrim T, Vloet LCM, Berben SAA. Risk stratification tools for patients with syncope in emergency medical services and emergency departments: a scoping review. Scand J Trauma Resusc Emerg Med 2023; 31:48. [PMID: 37723535 PMCID: PMC10508018 DOI: 10.1186/s13049-023-01102-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/16/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Patients with a syncope constitute a challenge for risk stratification in (prehospital) emergency care. Professionals in EMS and ED need to differentiate the high-risk from the low-risk syncope patient, with limited time and resources. Clinical decision rules (CDRs) are designed to support professionals in risk stratification and clinical decision-making. Current CDRs seem unable to meet the standards to be used in the chain of emergency care. However, the need for a structured approach for syncope patients remains. We aimed to generate a broad overview of the available risk stratification tools and identify key elements, scoring systems and measurement properties of these tools. METHODS We performed a scoping review with a literature search in MEDLINE, CINAHL, Pubmed, Embase, Cochrane and Web of Science from January 2010 to May 2022. Study selection was done by two researchers independently and was supervised by a third researcher. Data extraction was performed through a data extraction form, and data were summarised through descriptive synthesis. A quality assessment of included studies was performed using a generic quality assessment tool for quantitative research and the AMSTAR-2 for systematic reviews. RESULTS The literature search identified 5385 unique studies; 38 were included in the review. We discovered 19 risk stratification tools, one of which was established in EMS patient care. One-third of risk stratification tools have been validated. Two main approaches for the application of the tools were identified. Elements of the tools were categorised in history taking, physical examination, electrocardiogram, additional examinations and other variables. Evaluation of measurement properties showed that negative and positive predictive value was used in half of the studies to assess the accuracy of tools. CONCLUSION A total of 19 risk stratification tools for syncope patients were identified. They were primarily established in ED patient care; most are not validated properly. Key elements in the risk stratification related to a potential cardiac problem as cause for the syncope. These insights provide directions for the key elements of a risk stratification tool and for a more advanced process to validate risk stratification tools.
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Affiliation(s)
- Lucia G Uit Het Broek
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands.
| | - B Bastiaan A Ort
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Thomas Pelgrim
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Lilian C M Vloet
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Sivera A A Berben
- Research Department of Emergency and Critical Care, School of Health Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
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Wood BS, Craig MJ, Williamson M, Gehi AK. A Systematic Emergency Department Care Protocol for Syncope Patients Reduces Admissions. Am J Cardiol 2023; 202:160-162. [PMID: 37441829 DOI: 10.1016/j.amjcard.2023.06.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/28/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023]
Affiliation(s)
- Brian S Wood
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Michael J Craig
- Division of Hospital Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Meredith Williamson
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anil K Gehi
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
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15
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Moss L, Propersi ME, Karounos M. Syncope in the Emergency Department: Should We Be Using the Canadian Syncope Risk Score?: July 2023 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2023; 82:115-117. [PMID: 37349069 DOI: 10.1016/j.annemergmed.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Affiliation(s)
- Lynnsey Moss
- Department of Emergency Medicine, Nuvance Health at Vassar Brothers Medical Center, Poughkeepsie, NY
| | - Marco E Propersi
- Department of Emergency Medicine, Nuvance Health at Vassar Brothers Medical Center, Poughkeepsie, NY
| | - Marianna Karounos
- Department of Emergency Medicine, Nuvance Health at Vassar Brothers Medical Center, Poughkeepsie, NY
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Rouleau G, Thiruganasambandamoorthy V, Wu K, Ghaedi B, Nguyen PA, Desveaux L. Developing Implementation Strategies to Support the Uptake of a Risk Tool to Aid Physicians in the Clinical Management of Patients With Syncope: Systematic Theoretical and User-Centered Design Approach. JMIR Hum Factors 2023; 10:e44089. [PMID: 37310783 DOI: 10.2196/44089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND The Canadian Syncope Risk Score (CSRS) was developed to improve syncope management in emergency department settings. Evidence-based tools often fail to have the intended impact because of suboptimal uptake or poor implementation. OBJECTIVE In this paper, we aimed to describe the process of developing evidence-based implementation strategies to support the deployment and use of the CSRS in real-world emergency department settings to improve syncope management among physicians. METHODS We followed a systematic approach for intervention development, including identifying who needs to do what differently, identifying the barriers and enablers to be addressed, and identifying the intervention components and modes of delivery to overcome the identified barriers. We used the Behaviour Change Wheel to guide the selection of implementation strategies. We engaged CSRS end users (ie, emergency medicine physicians) in a user-centered design approach to generate and refine strategies. This was achieved over a series of 3 qualitative user-centered design workshops lasting 90 minutes each with 3 groups of emergency medicine physicians. RESULTS A total of 14 physicians participated in the workshops. The themes were organized according to the following intervention development steps: theme 1-identifying and refining barriers and theme 2-identifying the intervention components and modes of delivery. Theme 2 was subdivided into two subthemes: (1) generating high-level strategies and developing strategies prototypes and (2) refining and testing strategies. The main strategies identified to overcome barriers included education in the format of meetings, videos, journal clubs, and posters (to address uncertainty around when and how to apply the CSRS); the development of a web-based calculator and integration into the electronic medical record (to address uncertainty in how to apply the CSRS); a local champion (to address the lack of team buy-in); and the dissemination of evidence summaries and feedback through email communications (to address a lack of evidence about impact). CONCLUSIONS The ability of the CSRS to effectively improve patient safety and syncope management relies on broad buy-in and uptake across physicians. To ensure that the CSRS is well positioned for impact, a comprehensive suite of strategies was identified to address known barriers.
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Affiliation(s)
- Geneviève Rouleau
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Nursing Department, Université du Québec en Outaouais, Saint-Jérôme, QC, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Kelly Wu
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Bahareh Ghaedi
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Phuong Anh Nguyen
- Ottawa Hospital Research Institute, Ottawa Hospital, Ottawa, ON, Canada
| | - Laura Desveaux
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Francisco Pascual J, Jordan Marchite P, Rodríguez Silva J, Rivas Gándara N. Arrhythmic syncope: From diagnosis to management. World J Cardiol 2023; 15:119-141. [PMID: 37124975 PMCID: PMC10130893 DOI: 10.4330/wjc.v15.i4.119] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/02/2023] [Accepted: 04/10/2023] [Indexed: 04/20/2023] Open
Abstract
Syncope is a concerning symptom that affects a large proportion of patients. It can be related to a heterogeneous group of pathologies ranging from trivial causes to diseases with a high risk of sudden death. However, benign causes are the most frequent, and identifying high-risk patients with potentially severe etiologies is crucial to establish an accurate diagnosis, initiate effective therapy, and alter the prognosis. The term cardiac syncope refers to those episodes where the cause of the cerebral hypoperfusion is directly related to a cardiac disorder, while arrhythmic syncope is cardiac syncope specifically due to rhythm disorders. Indeed, arrhythmias are the most common cause of cardiac syncope. Both bradyarrhythmia and tachyarrhythmia can cause a sudden decrease in cardiac output and produce syncope. In this review, we summarized the main guidelines in the management of patients with syncope of presumed arrhythmic origin. Therefore, we presented a thorough approach to syncope work-up through different tests depending on the clinical characteristics of the patients, risk stratification, and the management of syncope in different scenarios such as structural heart disease and channelopathies.
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Affiliation(s)
- Jaume Francisco Pascual
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- Grup de Recerca Cardiovascular, Vall d’Hebron Institut de Recerca, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Pablo Jordan Marchite
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Jesús Rodríguez Silva
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
| | - Nuria Rivas Gándara
- Unitat d’Arritmies Servei de Cardiologia VHIR, Hospital Universitari Vall d’Hebron, Barcelona 08035, Spain
- CIBER de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid 28029, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
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Hudek N, Brehaut JC, Rowe BH, Nguyen PA, Ghaedi B, Ishimwe AC, Fabian C, Yan JW, Sivilotti MLA, Ohle R, Le Sage N, Mercier E, Archambault PM, Plourde M, Davis P, McRae AD, Hegdekar M, Thiruganasambandamoorthy V. Development of practice recommendations based on the Canadian Syncope Risk Score and identification of barriers and facilitators for implementation. CAN J EMERG MED 2023; 25:434-444. [PMID: 37058217 DOI: 10.1007/s43678-023-00498-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/19/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Wide variations in emergency department (ED) syncope management exist. The Canadian Syncope Risk Score (CSRS) was developed to predict the probability of 30-day serious outcomes after ED disposition. Study objectives were to evaluate the acceptability of proposed CSRS practice recommendations among providers and patients, and identify barriers and facilitators for CSRS use to guide disposition decisions. METHODS We conducted semi-structured interviews with 41 physicians involved in ED syncope and 35 ED patients with syncope. We used purposive sampling to ensure a variety of physician specialties and CSRS patient risk levels. Thematic analysis was completed by two independent coders with consensus meetings to resolve conflicts. Analysis proceeded in parallel with interviews until data saturation. RESULTS The majority (97.6%; 40/41) of physicians agreed with discharge of low risk (CSRS ≤ 0) but opined that 'no follow up' changed to 'follow-up as needed'. Physicians indicated current practices do not align with the medium-risk recommendation to discharge patients with 15-day monitoring (CSRS = 1-3; due to lack of access to monitors and timely follow-up) and the high-risk recommendation (CSRS ≥ 4) to potentially discharge patients with 15-day monitoring. Physicians recommended brief hospitalization of high-risk patients due to patient safety concerns. Facilitators included the CSRS-based patient education and scores supporting their clinical gestalt. Patients reported receiving varying levels of information regarding syncope and post-ED care, were satisfied with care received and preferred less resource intensive options. CONCLUSION Our recommendations based on the study results were: discharge of low-risk patients with physician follow-up as needed; discharge of medium-risk patients with 15-day cardiac monitoring and brief hospitalization of high-risk patients with 15-day cardiac monitoring if discharged. Patients preferred less resource intensive options, in line with CSRS recommended care. Implementation should leverage identified facilitators (e.g., patient education) and address the barriers (e.g., monitor access) to improve ED syncope care.
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Affiliation(s)
- Natasha Hudek
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jamie C Brehaut
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | | | | | | | - Christopher Fabian
- Department of Emergency Medicine, The Montfort Hospital, Ottawa, ON, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, ON, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine and Biomedical, and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - Robert Ohle
- Departments of Emergency Medicine, Health Science North, Sudbury, ON, Canada
- Health Sciences North Research Institute, Sudbury, ON, Canada
| | - Natalie Le Sage
- Department of Family Medicine and Emergency Medicine, Université Laval Université Laval, and CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- VITAM-Centre de recherche en santé durable, Québec, QC, Canada
| | - Eric Mercier
- Department of Family Medicine and Emergency Medicine, Université Laval Université Laval, and CHU de Québec-Université Laval Research Center, Québec, QC, Canada
| | - Patrick M Archambault
- Departments of Family Medicine and Emergency Medicine and Anesthesiology and Intensive Care Medicine, Université Laval, Québec, QC, Canada
- Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Miville Plourde
- Department of Family Medicine and Emergency Medicine, Université Laval Université Laval, and CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- Department of Family Medicine and Emergency Medicine, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Philip Davis
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Andrew D McRae
- Department of Emergency Medicine and Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program-Emergency Medicine, Department of Emergency Medicine, Clinical Epidemiology Unit, The Ottawa Hospital Research Institute, University of Ottawa, 1053 Carling Avenue, Ottawa, ON, F6K1Y 4E9, Canada.
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Kavi KS, Gall NP. Trauma and syncope: looking beyond the injury. Trauma Surg Acute Care Open 2023; 8:e001036. [PMID: 36744295 PMCID: PMC9896213 DOI: 10.1136/tsaco-2022-001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
Background 42% of the population experience syncope by the age of 70, accounting for up to 6% of hospital admissions that frequently present as falls. The etiologies of some falls are benign, and others, such as cardiac syncope, are associated with a greater mortality and must be identified. Methods This review article aims to bridge the literature gap by providing a comprehensive practice review and critical summary of the current syncope guidance relating to the trauma patient. Results The National Institute for Health and Care Excellence, the American College of Cardiology, and European Society of Cardiology published syncope risk stratification guidance. The inclusion of certain high-risk features represented in all three guidelines suggests their significance to identify cardiac syncope including heart failure, abnormal vital signs, syncope during exercise with little to no prodrome, family history of sudden cardiac death, and ECG abnormalities. Of 11 syncope risk stratification scoring systems based on these guidelines, only 2 are externally validated in the emergency department, neither of which are validated for major trauma use. Adherence to thorough history-taking, examination, orthostatic blood pressure recording, and an ECG can diagnose the cause of syncope in up to 50% of patients. ECG findings are 95% to 98% sensitive in the detection of serious adverse outcomes after cardiac syncope and should form part of a standardized syncope trauma assessment. Routine blood testing in trauma is often performed despite evidence that it is neither useful nor cost effective, where the screening of cardiac enzymes and D-dimer rarely influences management. Discussion In the absence of a gold-standard clinical test to identify the cause of a syncopal episode, standardized syncope guidelines as described in this review could be incorporated into trauma protocols to analyze high-risk etiologies, improve diagnostic accuracy, reduce unnecessary investigations, and develop an effective and safer management strategy.
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Affiliation(s)
- Kieran S Kavi
- Department of Emergency Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicholas P Gall
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
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Kiradoh SA, Craven TE, Rangel MO, Nosow LM, Zarrinkhoo E, Menon S, Chevli PA, Islam TM, Thazhatuveetil-Kunhahamed LA. Predicting short-term adverse outcomes in the geriatric population presenting with syncope: a comparison of existing syncope rules and beyond. J Geriatr Cardiol 2023; 20:11-22. [PMID: 36875169 PMCID: PMC9975484 DOI: 10.26599/1671-5411.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
OBJECTIVES Syncope at age 65+ is associated with increased mortality, irrespective of cause. Syncope rules were designed to aid in risk-stratification but were only validated in the general adult population. Our objective was to determine if they can be applied to a geriatric population in predicting short-term adverse outcomes. METHODS In this single-center retrospective study, we evaluated 350 patients aged 65+ presenting with syncope. Exclusion criteria included confirmed non-syncope, active medical condition, drug or alcohol-related syncope. Patients were stratified into high or low risk based on Canadian Syncope Risk Score (CSRS), Evaluation of Guidelines in Syncope Study (EGSYS), San Francisco Syncope Rule (SFSR), and Risk Stratification of Syncope in the Emergency Department (ROSE). Composite adverse outcomes at 48-hour and 30-day included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), return emergency department visit, hospitalization, or medical intervention. We assessed each score's ability to predict the outcomes using logistic-regression and compared performances using receiver-operator curves. Multivariate analyses were performed to study the associations between recorded parameters and outcomes. RESULTS CSRS outperformed with AUC of 0.732 (95% CI: 0.653-0.812) and 0.749 (95% CI: 0.688-0.809) for 48-h and 30-day outcomes, respectively. Sensitivities for CSRS, EGSYS, SFSR, and ROSE for 48-hour outcomes were 48%, 65%, 42% and 19%; and for 30-day outcomes were 72%, 65%, 30% and 55%, respectively. Atrial fibrillation/flutter on EKG, congestive heart failure, antiarrhythmics, systolic blood-pressure < 90 at triage, and associated chest pain highly correlated with 48-h outcomes. An EKG abnormality, heart disease history, severe pulmonary hypertension, BNP > 300, vasovagal predisposition, and antidepressants highly correlated with 30-day outcomes. CONCLUSIONS Performance and accuracy of four prominent syncope rules were suboptimal in identifying high-risk geriatric patients with short-term adverse outcomes. We identified some significant clinical and laboratory information that may play a role in predicting short-term adverse events in a geriatric cohort.
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Affiliation(s)
- Suud A Kiradoh
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Timothy E Craven
- Biostatistics, Epidemiology, Research, and Design (BERD), Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Maria O Rangel
- Department of Cardiology, Atrium Health Wake Forest Baptist Medical Center, USA
| | - Lillian M Nosow
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Erfan Zarrinkhoo
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Suma Menon
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Parag A Chevli
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - Tareq M Islam
- Department of Internal Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, USA
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21
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Voigt RD, Alsayed M, Bellolio F, Campbell RL, Mullan A, Colleti JE, Oliveira J. e Silva L. Prognostic accuracy of syncope clinical prediction rules in older adults in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12820. [PMID: 36311342 PMCID: PMC9597095 DOI: 10.1002/emp2.12820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/03/2022] [Accepted: 07/14/2022] [Indexed: 11/06/2022] Open
Abstract
Study objective The objective of this study is to evaluate the prognostic accuracy of existing rules (San Francisco Syncope Rule [SFSR], Canadian Syncope Risk Score [CSRS], and FAINT score) in older adults. Methods This is a cohort study of adults aged ≥60 years presenting to an academic emergency department (ED) with syncope or near syncope. We used original criteria for all rules except for the FAINT score, in which N-terminal pro-brain natriuretic peptide was largely missing from the extracted data. Patients were deemed positive for each rule if classified as non-low risk. The primary outcome was the presence of 30-day serious outcome, as defined by syncope research guidelines. Sensitivity and negative likelihood ratio (NLR) were calculated with 95% confidence intervals (CIs). Results A total of 404 ED visits (mean age of patients, 75.5 years) were included. Of these, 44 (10.9%) had a 30-day serious outcome, and 24 (5.9%) had incomplete 30-day follow-up. SFSR was positive for 280 of 380 visits with complete follow-up. Its sensitivity and NLR for predicting 30-day serious outcomes were 86.4% (95% CI, 72.0%-94.3%) and 0.53 (95% CI, 0.25-1.15), respectively. The CSRS was positive for 299 of 380 visits (sensitivity was 88.6% [95% CI, 76.4%-95.7%], and NLR was 0.50 [95% CI, 0.22-1.17]). The modified FAI(N)T score was positive for 318 of 380 visits (sensitivity was 90.9% [95% CI, 77.4%-97.0%], and NLR was 0.53 [95% CI, 0.20-1.38]). Conclusion Existing rules are suboptimal to predict 30-day serious outcomes in older adults presenting with syncope or near syncope to the ED.
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Affiliation(s)
- Richard D. Voigt
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA
| | - Momen Alsayed
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA
| | - Fernanda Bellolio
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA
- Department of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | | | - Aidan Mullan
- Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | - James E. Colleti
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA
| | - Lucas Oliveira J. e Silva
- Department of Emergency MedicineMayo ClinicRochesterMinnesotaUSA
- Department of Emergency MedicineHospital de Clínicas de Porto AlegrePorto AlegreRSBrazil
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22
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Xiao X, William J, Kistler PM, Joseph S, Patel HC, Vaddadi G, Kalman JM, Mariani JA, Voskoboinik A. Prediction of Pacemaker Requirement in Patients With Unexplained Syncope: The DROP Score. Heart Lung Circ 2022; 31:999-1005. [PMID: 35370087 DOI: 10.1016/j.hlc.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/18/2022] [Accepted: 03/04/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Implantable loop recorders (ILR) are increasingly utilised in the evaluation of unexplained syncope. However, they are expensive and do not protect against future syncope. OBJECTIVES To compare patients requiring permanent pacemaker (PPM) implantation during ILR follow-up with those without abnormalities detected on ILR in order to identify potential predictors of benefit from upfront pacing. METHODS We analysed 100 consecutive patients receiving ILR: Group 1 (n=50) underwent PPM insertion due to bradyarrhythmias detected on ILR; Group 2 (n=50) had no arrhythmias detected on ILR over >3 years follow-up. Baseline clinical characteristics, syncope history, electrocardiographic and echocardiographic parameters were assessed to identify predictors of ultimate requirement for pacing. RESULTS Group 1 (64% male, median age 70.8 years; IQR 65.5-78.8) were older than Group 2 (58% male, median 60.2 years; IQR 44.0-73.0 p=0.001) and were less likely to have related historical factors such as overheating, posture and exercise (98% vs 70% p<0.001). PR interval was also longer in Group 1 (192±51 vs 169±23 p=0.006) with greater prevalence of distal conduction system disease (30% vs 4.3% p=0.002). Significant univariate predictors for PPM insertion were distal conduction disease (p=0.007), first degree atrioventricular (AV) block (p=0.003), absence of precipitating factors (p=0.004), and age >65 years (p=0.001). Injury sustained, recurrent syncope, history of atrial fibrillation (AF) or heart failure, left atrial (LA) size and left ventricular ejection fraction (LVEF) were not predictive. These significant predictors were incorporated into the DROP score1 (0-4). Using time-to-event analysis, no patients with a score of 0 progressed to pacing, while higher scores (3-4) strongly predicted pacing requirement (log-rank p<0.001). CONCLUSION The DROP score may be helpful in identifying patients likely to benefit from upfront permanent pacemaker (PPM) insertion following unexplained syncope. Larger prospective studies are required to validate this tool.
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Affiliation(s)
- Xiaoman Xiao
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Jeremy William
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Peter M Kistler
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia; The Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia
| | - Stephen Joseph
- Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia
| | - Hitesh C Patel
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia; The Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Gautam Vaddadi
- Department of Cardiology, Northern Health, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia
| | - Jonathan M Kalman
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Justin A Mariani
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia; The Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Cardiology, Cabrini Health, Melbourne, Vic, Australia.
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23
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Moussa BS, Ali MA, Ali AAEN, Abou Zeid AELSM. Assessment of Canadian Syncope Risk Score in the prediction of outcomes of patients with syncope at the Emergency Department of Suez Canal University: STROBE compliant. Medicine (Baltimore) 2022; 101:e29287. [PMID: 35758358 PMCID: PMC9276233 DOI: 10.1097/md.0000000000029287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 12/04/2022] Open
Abstract
ABSTRACT Syncope is a temporary loss of consciousness usually related to insufficient blood flow to the brain. It's also called fainting or "passing out." Syncope is responsible for 3% to 5% of emergency department visits, with a hospitalization rate in about 40% of cases, with an average stay of 5.5 days. The Canadian Syncope Risk Score showed good discrimination and calibration for 30-day risk of serious adverse events after disposition from the emergency department.The aim was to assess Canadian Syncope Risk Score in predicting outcomes and mortality at the emergency department of Suez Canal University Hospitals.A prospective observational cohort study was carried out in emergency department in Suez Canal University Hospital. After approval by the Ethical and Research Committee of Faculty of Medicine, Suez Canal University, 60 patients with syncope attending to emergency department were included to this study. All included participants were assessed by history taking and they also assessed by the Canadian Syncope Risk Score.The Canadian Syncope Risk Score's mean of the study group was 4.9 and the range of the scores was from -2 to 11. The mean of the percentage of risk of serious events at 30 days in the study group was 29.17% and it ranged from 0.7% to 83.6%.There was a statistically significant difference between means Canadian Syncope Risk Score's score regarding complication occurrence. Cases which showed complications had a mean score of 7.33 compared to a mean score of 1.25 in case of no complication occurrence P-value <.001. At a cut-off point of more than 3 for the Canadian Syncope Risk Score's, sensitivity of that score in complication's occurrence prediction was 100% and the specificity was 87.5% P-value <.001.The Canadian Syncope Risk Score's is strong predictor for risk of serious adverse events and a good indicator for admission, with 100% sensitivity and 87.5% specificity at cut off point more than 3.
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Affiliation(s)
- Bassant Sayed Moussa
- Emergency Medicine, Department Faculty of Medicine, Suez Canal University, Egypt
| | - Mohamed Amin Ali
- Lecturer of Emergency Medicine Department Faculty of Medicine, Suez Canal University
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Probst MA, Janke AT, Haimovich AD, Venkatesh AK, Lin MP, Kocher KE, Nemnom MJ, Thiruganasambandamoorthy V. Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations. Ann Emerg Med 2022; 79:509-517. [PMID: 35487840 PMCID: PMC9117517 DOI: 10.1016/j.annemergmed.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite evidence supporting risk stratification and outpatient management, variation in syncope hospitalization rates persist. We sought to develop a new quality measure for very low-risk adult ED patients with syncope that could be applied to administrative data. METHODS We developed this quality measure in 2 phases. First, we used an existing prospective, observational ED patient data set to identify a very low-risk cohort with unexplained syncope using 2 variables: age less than 50 years and no history of heart disease. We then applied this to the 2019 Nationwide Emergency Department Sample (NEDS) to assess its potential effect, assessing for hospital-level factors associated with hospitalization variation. RESULTS Of the 8,647 adult patients in the prospective cohort, 3,292 (38%) patients fulfilled these 2 criteria: age less than 50 years and no history of heart disease. Of these, 15 (0.46%) suffered serious adverse events within 30 days. In the NEDS, there were an estimated 566,031 patients meeting these 2 criteria, of whom 15,507 (2.7%; 95% confidence interval [CI] 2.48% to 3.00%) were hospitalized. We found substantial variation in the hospitalization rates for this very low-risk cohort, with a median rate of 1.7% (range 0% to 100%; interquartile range 0% to 3.9%). Factors associated with increased hospitalization rates included a yearly ED volume of more than 80,000 (odds ratio [OR] 3.14; 95% CI 2.02 to 4.89) and metropolitan teaching status (OR 1.5; 95% CI 1.24 to 1.81). CONCLUSION In summary, our novel syncope quality measure can assess variation in low-value hospitalizations for unexplained syncope. The application of this measure could improve the value of syncope care.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Columbia University Medical Center, New York, NY.
| | - Alexander T Janke
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Adrian D Haimovich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Michelle P Lin
- Department of Emergency Medicine and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith E Kocher
- Department of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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25
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Grant L, Joo P, Nemnom MJ, Thiruganasambandamoorthy V. Machine learning versus traditional methods for the development of risk stratification scores: a case study using original Canadian Syncope Risk Score data. Intern Emerg Med 2022; 17:1145-1153. [PMID: 34734350 DOI: 10.1007/s11739-021-02873-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/13/2021] [Indexed: 12/23/2022]
Abstract
Artificial Intelligence and machine learning (ML) methods are promising for risk-stratification, but the added benefit over traditional statistical methods remains unclear. We compared predictive models developed using machine learning (ML) methods to the Canadian Syncope Risk Score (CSRS), a risk-tool developed with logistic regression for predicting serious adverse events (SAE) after emergency department (ED) disposition for syncope. We used the prospective multicenter cohort data collected for CSRS development at 11 Canadian EDs over an 8-year period to develop four ML models to predict 30-day SAE (death, arrhythmias, MI, structural heart disease, pulmonary embolism, hemorrhage) after ED disposition. The CSRS derivation and validation cohorts were used for training and testing, respectively, and the 43 variables used included demographics, medical history, vital signs, ECG findings, blood tests and the diagnostic impression of the emergency physician. Performance was assessed using the area under the receiver-operating-characteristics curve (AUC) and calibration curves. Of the 4030 patients in the training set and 3819 patients in the test set overall, 286 (3.6%) patients suffered 30-day SAE. The AUCs for model validation in test data were CSRS 0.902 (0.877-0.926), regularized regression 0.903 (0.877-0.928), gradient boosting 0.914 (0.894-0.934), deep neural network 0.906 (0.883-0.929), simplified gradient boosting 0.904 (0.881-0.927). The AUCs and calibration slopes for the ML models and CSRS were similar. Two ML models used fewer predictors than the CSRS but matched its performance. Overall, the ML models matched the CSRS in performance, with some models using fewer predictors.
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Affiliation(s)
- Lars Grant
- Department of Emergency Medicine, McGill University, Montreal, QC, Canada
- Lady Davis Research Institute, Montreal, QC, Canada
- Jewish General Hospital, Montreal, QC, Canada
| | - Pil Joo
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Emergency Medicine, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Venkatesh Thiruganasambandamoorthy
- The Ottawa Hospital, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Emergency Medicine, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
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26
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Zimmermann T, du Fay de Lavallaz J, Nestelberger T, Gualandro DM, Lopez-Ayala P, Badertscher P, Widmer V, Shrestha S, Strebel I, Glarner N, Diebold M, Miró Ò, Christ M, Cullen L, Than M, Martin-Sanchez FJ, Di Somma S, Peacock WF, Keller DI, Bilici M, Costabel JP, Kühne M, Breidthardt T, Thiruganasambandamoorthy V, Mueller C, Belkin M, Leu K, Lohrmann J, Boeddinghaus J, Twerenbold R, Koechlin L, Walter JE, Amrein M, Wussler D, Freese M, Puelacher C, Kawecki D, Morawiec B, Salgado E, Martinez-Nadal G, Inostroza CIF, Mandrión JB, Poepping I, Rentsch K, von Eckardstein A, Buser A, Greenslade J, Reichlin T, Bürgler F. International Validation of the Canadian Syncope Risk Score : A Cohort Study. Ann Intern Med 2022; 175:783-794. [PMID: 35467933 DOI: 10.7326/m21-2313] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The Canadian Syncope Risk Score (CSRS) was developed to predict 30-day serious outcomes not evident during emergency department (ED) evaluation. OBJECTIVE To externally validate the CSRS and compare it with another validated score, the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) score. DESIGN Prospective cohort study. SETTING Large, international, multicenter study recruiting patients in EDs in 8 countries on 3 continents. PARTICIPANTS Patients with syncope aged 40 years or older presenting to the ED within 12 hours of syncope. MEASUREMENTS Composite outcome of serious clinical plus procedural events (primary outcome) and the primary composite outcome excluding procedural interventions (secondary outcome). RESULTS Among 2283 patients with a mean age of 68 years, the primary composite outcome occurred in 7.2%, and the composite outcome excluding procedural interventions occurred in 3.1% at 30 days. Prognostic performance of the CSRS was good for both 30-day composite outcomes and better compared with the OESIL score (area under the receiver-operating characteristic curve [AUC], 0.85 [95% CI, 0.83 to 0.88] vs. 0.74 [CI, 0.71 to 0.78] and 0.80 [CI, 0.75 to 0.84] vs. 0.69 [CI, 0.64 to 0.75], respectively). Safety of triage, as measured by the frequency of the primary composite outcome in the low-risk group, was higher using the CSRS (19 of 1388 [0.6%]) versus the OESIL score (17 of 1104 [1.5%]). A simplified model including only the clinician classification of syncope (cardiac syncope, vasovagal syncope, or other) variable at ED discharge-a component of the CSRS-achieved similar discrimination as the CSRS (AUC, 0.83 [CI, 0.80 to 0.87] for the primary composite outcome). LIMITATION Unable to disentangle the influence of other CSRS components on clinician classification of syncope at ED discharge. CONCLUSION This international external validation of the CSRS showed good performance in identifying patients at low risk for serious outcomes outside of Canada and superior performance compared with the OESIL score. However, clinician classification of syncope at ED discharge seems to explain much of the performance of the CSRS in this study. The clinical utility of the CSRS remains uncertain. PRIMARY FUNDING SOURCE Swiss National Science Foundation & Swiss Heart Foundation.
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Affiliation(s)
- Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.Z.)
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.N.)
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, GREAT Network, Rome, Italy, and Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil (D.M.G.)
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Velina Widmer
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Samyut Shrestha
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland (V.W., N.G.)
| | - Matthias Diebold
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Òscar Miró
- GREAT Network, Rome, Italy, and Hospital Clinic, Barcelona, Catalonia, Spain (Ò.M.)
| | - Michael Christ
- GREAT Network, Rome, Italy, and Kantonsspital Luzern, Luzern, Switzerland (M.C.)
| | - Louise Cullen
- GREAT Network, Rome, Italy, and Royal Brisbane & Women's Hospital, Herston, Australia (L.C.)
| | - Martin Than
- GREAT Network, Rome, Italy, and Christchurch Hospital, Christchurch, New Zealand (M.T.)
| | - F Javier Martin-Sanchez
- GREAT Network, Rome, Italy, and Servicio de Urgencias, Hospital Clínico San Carlos, Madrid, Spain (F.J.M.)
| | - Salvatore Di Somma
- GREAT Network, Rome, Italy, and Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Italy (S.D.S.)
| | - W Frank Peacock
- GREAT Network, Rome, Italy, and Baylor College of Medicine, Department of Emergency Medicine, Houston, Texas (W.F.P.)
| | - Dagmar I Keller
- Emergency Department, University Hospital Zürich, Zürich, Switzerland (D.I.K.)
| | - Murat Bilici
- Department of Orthopedics and Traumatology, University Hospital Basel, University of Basel, Basel, Switzerland (M.B.)
| | | | - Michael Kühne
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
| | - Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, and Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (T.B.)
| | | | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland, and GREAT Network, Rome, Italy (J.F.L., P.L., P.B., S.S., I.S., M.D., M.K., C.M.)
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Sutton R, Ricci F, Fedorowski A. Risk stratification of syncope: Current syncope guidelines and beyond. Auton Neurosci 2022; 238:102929. [PMID: 34968831 DOI: 10.1016/j.autneu.2021.102929] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/27/2021] [Accepted: 12/08/2021] [Indexed: 11/28/2022]
Abstract
Syncope is an alarming event carrying the possibility of serious outcomes, including sudden cardiac death (SCD). Therefore, immediate risk stratification should be applied whenever syncope occurs, especially in the Emergency Department, where most dramatic presentations occur. It has long been known that short- and long-term syncope prognosis is affected not only by its mechanism but also by presence of concomitant conditions, especially cardiovascular disease. Over the last two decades, several syncope prediction tools have been developed to refine patient stratification and triage patients who need expert in-hospital care from those who may receive nonurgent expert care in the community. However, despite promising results, prognostic tools for syncope remain challenging and often poorly effective. Current European Society of Cardiology syncope guidelines recommend an initial syncope workup based on detailed patient's history, physical examination supine and standing blood pressure, resting ECG, and laboratory tests, including cardiac biomarkers, where appropriate. Subsequent risk stratification based on screening of features aims to identify three groups: high-, intermediate- and low-risk. The first should immediately be hospitalized and appropriately investigated; intermediate group, with recurrent or medium-risk events, requires systematic evaluation by syncope experts; low-risk group, sporadic reflex syncope, merits education about its benign nature, and discharge. Thus, initial syncope risk stratification is crucial as it determines how and by whom syncope patients are managed. This review summarizes the crucial elements of syncope risk stratification, pros and cons of proposed risk evaluation scores, major challenges in initial syncope management, and how risk stratification impacts management of high-risk/recurrent syncope.
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Affiliation(s)
- Richard Sutton
- National Heart & Lung Institute, Imperial College, Dept. of Cardiology, Hammersmith Hospital, Du Cane Road, London W12 0HS, United Kingdom
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G.d'Annunzio" University of Chieti-Pescara, Via Luigi Polacchi, 11, 66100 Chieti, Italy; Casa di Cura Villa Serena, Città Sant'Angelo, Italy
| | - Artur Fedorowski
- Dept. of Cardiology, Karolinska University Hospital, and Department of Medicine, Karolinska Institute, Stockholm, Sweden.
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Simos P, Scott I. Appropriate use of transthoracic echocardiography in the investigation of general medicine patients presenting with syncope or presyncope. Postgrad Med J 2022; 99:postgradmedj-2021-141416. [PMID: 35169024 DOI: 10.1136/postgradmedj-2021-141416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/22/2022] [Indexed: 01/03/2023]
Abstract
STUDY PURPOSE Routine transthoracic echocardiography (TTE) in patients with syncope or presyncope is resource-intensive. We assessed if risk thresholds defined by a validated risk score may identify patients at low risk of cardiac abnormality in whom TTE is unnecessary. STUDY DESIGN We conducted a retrospective study of all general medicine patients with syncope/presyncope presenting to a tertiary hospital between July 2016 and September 2020 and who underwent TTE. The Canadian Syncope Risk Score (CSRS) was used to categorise patients as low to very low risk (score -3 to 0) or moderate to high risk (score ≥1) for serious adverse events at 30 days. A cut-point of 0 was used to calculate the sensitivity, specificity, positive and negative predictive values (PPV and NPV) for CSRS and the odds ratio (OR) of a clinically significant finding on TTE in patients with CSRS ≥1 compared with all patients. RESULTS Among 157 patients, the CSRS categorised 69 (44%) as very low to low risk in whom TTE was normal. In 88 patients deemed moderate to high risk, TTE detected a cardiac abnormality in 24 (27%). A CSRS ≥1 yielded a sensitivity of 100% (95% CI 85.7% to 100%), specificity of 51.1% (95% CI 42.3% to 59.8%), PPV of 26.5% (95% CI 26.3% to 30.1%) and NPV of 100% (95% CI 92.5% to 100%) for cardiac abnormalities and doubled the odds of an abnormality (OR=2.05, 95% CI 1.08 to 3.87, p=0.028). CONCLUSION In general medicine patients with syncope/presyncope, using the CSRS to stratify risk of a cardiac abnormality on TTE can almost halve TTE use.
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Affiliation(s)
- Peter Simos
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia .,School of Clinical Medicine, University of Queensland Faculty of Health and Behavioural Sciences, Herston, Queensland, Australia
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Almulhim KN. The Characteristics of Syncope-Related Emergency Department Visits: Resource Utilization and Admission Rate Patterns in Emergency Departments. Cureus 2022; 14:e22039. [PMID: 35340474 PMCID: PMC8913182 DOI: 10.7759/cureus.22039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective Decision-making about syncope patients presenting to the emergency department (ED) is challenging since physicians must balance the minimal risks of life-threatening conditions with the unessential use of expensive imaging or unnecessary hospitalizations. This study aimed to determine the characteristics of ED visits, resource utilization, and admission rate patterns related to syncope in the United States (US) during the period 2005-2015. Methods Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) on ED visits during the 11-year period from 2005 to 2015 were retrieved. ED visits for syncope were identified and compared against non-syncope ED visits. The demographic and clinical characteristics of patients, as well data on resource allocation and admission trends were captured and described for the syncope and the non-syncope groups. Results Syncope accounted for 1.11% of the total ED visits during the study period from 2005 to 2015. The incidence of syncope-related ED visits was higher among elderly females, whites, and non-Hispanics. The trend of admission rates showed a decline from about 30% in 2005-2010 to less than 20% in 2014 and 2015. Advanced imaging (CT or MRI) was ordered for 34% of syncope patients. Conclusion The percentage of syncope-related ED visits remained stable during the study period, but the admission rates declined while the use of advanced imaging in syncope-related ED visits remained substantially high despite the advances in research and availability of clinical guidelines. Future research is needed to rationalize healthcare utilization in syncope-related ED visits and precisely identify the high-risk population.
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Liang Y, Li X, Tse G, King E, Roever L, Li G, Liu T. Syncope Prediction Scores in the Emergency Department. Curr Cardiol Rev 2022; 18:1-7. [PMID: 35319380 PMCID: PMC9896417 DOI: 10.2174/1573403x18666220321104129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/03/2021] [Accepted: 01/10/2022] [Indexed: 11/22/2022] Open
Abstract
Syncope is a common clinical presentation defined as a transient loss of consciousness (TLOC) due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. Different clinical decision rules (CDRs) and risk stratification scores have been developed to predict short- and long-term risks for adverse outcomes after syncope. The central theme of these prediction systems is consistent with the ESC syncope guidelines. Initial assessment according to the ESC guideline is essential until an optimal and well-validated risk score is available. The focus should be accurate risk stratification to allow prevention of adverse outcomes and optimize the use of limited healthcare resources. In this review article, we summarize and critically appraise the evidence regarding the CDRs for patients presenting with syncope.
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Affiliation(s)
- Yan Liang
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
| | - Xiulian Li
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
| | - Gary Tse
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, China
| | - Emma King
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, China
| | | | - Guangping Li
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
| | - Tong Liu
- Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Pingjiang Road, Hexi District, Tianjin 300211, People’s Republic of China
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Safari S, Khasraghi ZS, Chegeni MA, Ghabousian A, Amini A. The ability of Canadian Syncope risk score in differentiating cardiogenic and non-cardiogenic syncope; a cross-sectional study. Am J Emerg Med 2021; 50:675-678. [PMID: 34879485 DOI: 10.1016/j.ajem.2021.07.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Determining the underlying etiology of syncope provides valuable prognostic information and expedites the implementation of a therapeutic strategy. This study aimed to evaluate the ability of Canadian Syncope Risk Score (CSRS) in differentiating cardiogenic and non-cardiac syncope. METHODS The present diagnostic accuracy study was conducted on adult patients with syncope, who presented to the emergency departments of Shohadaye Tajrish and Imam Hossein Hospitals in Tehran from March 2018 to March 2019. The data required for determining CSRS were collected during the initial assessment and the underlying etiology was confirmed through further diagnostic follow-up under the supervision of a cardiologist or neurologist. Finally, the screening performance characteristics of the score were calculated. RESULTS 300 patients with the mean age of 56.38 ± 19.10 years were studied. The source of syncope was cardiac in 133 (44.3%) and non-cardiac in 137 (55.7%) patients. The area under the ROC curve of CSRS in differentiating cardiac syncope was 0.77 (95% CI: 0.715-0.824). At a cutoff point of -1.5, the sensitivity and specificity of the score were calculated to be 73.68% (95% CI: 65.21-80.75%) and 73.05% (95%CI: 75.54-79.47%), respectively. CONCLUSION The present study reveals that CSRS has fair accuracy in differentiating the source of syncope and has no superiority over a clinical examination. Therefore, we do not recommend relying on the CSRS to differentiate between cardiac and non-cardiac syncope alone.
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Affiliation(s)
- Saeed Safari
- Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Emergency Medicine Department, Shohadaye Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Soltanzadeh Khasraghi
- Emergency Medicine Department, Shohadaye Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Ahmadi Chegeni
- Emergency Medicine Department, Shohadaye Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Ghabousian
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Afshin Amini
- Emergency Medicine Department, Imam Hossein Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Hatoum T, Sheldon RS. Syncope and the aging patient: Navigating the challenges. Auton Neurosci 2021; 237:102919. [PMID: 34856496 DOI: 10.1016/j.autneu.2021.102919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
Syncope in the elderly patient is a common presentation and the most common causes are usually non-cardiac. Older adults however are more challenging dilemmas as their presentation is complicated by co-morbidities, mainly cardiovascular and neurodegenerative disorders. Frailty and cognitive impairment add to the ambiguity of the presentation, and polypharmacy is often a major modifiable contributing factor. Vasovagal syncope is a common presentation throughout life even as we age. It has a favorable prognosis and conservative management usually suffices. Vasovagal syncope in this population may be misdiagnosed as accidental falls and is frequently associated with injury, as is carotid sinus syndrome. The initial approach to these patients entails a detailed history and physical examination including a comprehensive medication history, orthostatic vital signs, and a 12-lead electrocardiogram. Further cardiac and neuroimaging rarely helps, unless directed by specific clinical findings. Head-up tilt testing and carotid sinus massage retain their diagnostic accuracy and safety in the elderly, and implantable loop recorders provide important information in many elderly patients with unexplained falls and syncope. The starting point in management of this population with non-cardiac syncope is attempting to withdraw unnecessary vasoactive and psychotropic medications. Non-pharmacologic and pharmacologic therapy for syncope in the elderly has limited efficacy and safety concerns. In selected patients, pacemaker therapy might offer symptomatic relief despite lack of efficacy when vasodepression is prominent. An approach focused on primary care with targeted specialist referral seems a safe and effective strategy.
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Affiliation(s)
- Tarek Hatoum
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.
| | - Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
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Thiruganasambandamoorthy V, Yan JW, Rowe BH, Mercier É, Le Sage N, Hegdekar M, Finlayson A, Huang P, Mohammad H, Mukarram M, Nguyen PAI, Syed S, McRae AD, Nemnom MJ, Taljaard M, Silviotti MLA. Personalised risk prediction following emergency department assessment for syncope. Emerg Med J 2021; 39:501-507. [PMID: 34740890 DOI: 10.1136/emermed-2020-211095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/26/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Published risk tools do not provide possible management options for syncope in the emergency department (ED). Using the 30-day observed risk estimates based on the Canadian Syncope Risk Score (CSRS), we developed personalised risk prediction to guide management decisions. METHODS We pooled previously reported data from two large cohort studies, the CSRS derivation and validation cohorts, that prospectively enrolled adults (≥16 years) with syncope at 11 Canadian EDs between 2010 and 2018. Using this larger cohort, we calculated the CSRS calibration and discrimination, and determined with greater precision than in previous studies the 30-day risk of adjudicated serious outcomes not identified during the index ED evaluation depending on the CSRS and the risk category. Based on these findings, we developed an on-line calculator and pictorial decision aids. RESULTS 8233 patients were included of whom 295 (3.6%, 95% CI 3.2% to 4.0%) experienced 30-day serious outcomes. The calibration slope was 1.0, and the area under the curve was 0.88 (95% CI 0.87 to 0.91). The observed risk increased from 0.3% (95% CI 0.2% to 0.5%) in the very-low-risk group (CSRS -3 to -2) to 42.7% (95% CI 35.0% to 50.7%), in the very-high-risk (CSRS≥+6) group (Cochrane-Armitage trend test p<0.001). Among the very-low and low-risk patients (score -3 to 0), ≤1.0% had any serious outcome, there was one death due to sepsis and none suffered a ventricular arrhythmia. Among the medium-risk patients (score +1 to+3), 7.8% had serious outcomes, with <1% death, and a serious outcome was present in >20% of high/very-high-risk patients (score +4 to+11) including 4%-6% deaths. The online calculator and the pictorial aids can be found at: https://teamvenk.com/csrs CONCLUSIONS: 30-day observed risk estimates from a large cohort of patients can be obtained for management decision-making. Our work suggests very-low-risk and low-risk patients may be discharged, discussion with patients regarding investigations and disposition are needed for medium-risk patients, and high-risk patients should be hospitalised. The online calculator, accompanied by pictorial decision aids for the CSRS, may assist in discussion with patients.
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Affiliation(s)
- Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Éric Mercier
- Department of Family Medicine and Emergency Medicine, Universite Laval Faculte de Medecine, Quebec, Quebec, Canada.,CHU de Québec-Université Laval Research Centre, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Natalie Le Sage
- Department of Family Medicine and Emergency Medicine, Universite Laval Faculte de Medecine, Quebec, Quebec, Canada.,CHU de Québec-Université Laval Research Centre, CHU de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - Mona Hegdekar
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anne Finlayson
- Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Huang
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Hassan Mohammad
- Faculty of Technology and Trades, Algonquin College, Ottawa, Ontario, Canada
| | - Muhammad Mukarram
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Phuong Anh Iris Nguyen
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shahbaz Syed
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, and Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Marco LA Silviotti
- Departments of Emergency Medicine and Biomedical, and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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Lewton AK, Morris LE. Validated scoring system identifies low-risk syncope patients. THE JOURNAL OF FAMILY PRACTICE 2021; 70:454-456. [PMID: 34818153 PMCID: PMC8619809 DOI: 10.12788/jfp.0309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This study validated the Canadian Syncope Risk Score for predicting 30-day serious outcomes in patients presenting to the ED within 24 hours of syncope.
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Affiliation(s)
- Amanda Kay Lewton
- University of Missouri Department of Family & Community Medicine, Columbia
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35
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Can I Send This Syncope Patient Home From the Emergency Department? J Emerg Med 2021; 61:801-809. [PMID: 34535304 DOI: 10.1016/j.jemermed.2021.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/18/2021] [Accepted: 07/25/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Syncope is a common presentation to the emergency department (ED). A significant minority of these patients have potentially life-threatening pathology. Reliably identifying that patients require hospital admission for further workup and intervention is imperative. CLINICAL QUESTION In patients who present with syncope, is there a reliable decision tool that clinicians can use to predict the risk of adverse outcome and determine who may be appropriate for discharge? EVIDENCE REVIEW Four articles were reviewed. The first retrospective study found no difference in mortality or adverse events in patients admitted for further evaluation rather than discharged home with primary care follow-up. The next two articles examined the derivation and validation of the Canadian Syncope Risk Score (CSRS). After validation with an admission threshold score of -1, the sensitivity and specificity of the CSRS was 97.8% (95% confidence interval [CI] 93.8-99.6%) and 44.3% (95% CI 42.7-45.9%), respectively. The last article looked at the derivation of the FAINT score, a recently developed score to risk stratify syncope patients. A FAINT score of ≥ 1 (any score 1 or higher should be admitted) had a sensitivity of 96.7% (95% CI 92.9-98.8%) and specificity 22.2% (95% CI 20.7-23.8%). CONCLUSIONS Syncope remains a difficult chief symptom to disposition from the ED. The CSRS is modestly effective at establishing a low probability of actionable disease or need for intervention. However, CSRS might not reduce unnecessary hospitalizations. The FAINT score has yet to undergo validation; however, the initial derivation study offers less diagnostic accuracy compared with the CSRS.
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Sutton R. Syncope presenting to the emergency department. J Intern Med 2021; 290:755-756. [PMID: 33586173 DOI: 10.1111/joim.13258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/18/2022]
Affiliation(s)
- R Sutton
- From the, Department of Cardiology, Hammersmith Hospital Campus, National Heart & Lung Institute, Imperial College, London, UK
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Chan J, Ballard E, Brain D, Hocking J, Yan A, Morel D, Hunter J. External validation of the Canadian Syncope Risk Score for patients presenting with undifferentiated syncope to the emergency department. Emerg Med Australas 2021; 33:418-424. [PMID: 33052034 DOI: 10.1111/1742-6723.13641] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/08/2020] [Accepted: 08/29/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To validate the accuracy and safety of the Canadian Syncope Risk Score (CSRS) for patients presenting with syncope. METHODS Single centre prospective observational study in Brisbane, Australia. Adults presenting to the ED with syncope within the last 24 h were recruited after applying exclusion criteria. Study was conducted over 1 year, from March 2018 to March 2019. Thirty-day serious adverse events (SAE) were reported based on the original derivation study and standardised outcome reporting for syncope. Individual patient CSRS was calculated and correlated with 30-day SAE and disposition status from ED. RESULTS Two hundred and eighty-three patients were recruited to the study. Average age was 55.6 years (SD 22.7 years), 37.1% being male with a 39.9% admission rate. Thirty-day SAE occurred in seven patients (2.5%) and no recorded deaths. The CSRS performed with a sensitivity of 71.4% (95% confidence interval [CI] 30.3-94.9%), specificity 72.8% (95% CI 67.1-77.9%) for a threshold score of 1 or higher. CONCLUSION Syncope patients in our study were predominantly very low to low risk (72%). The prevalence of 30-day SAE was low, majority occurring following hospital discharge. Sensitivity estimates for CSRS was lower than the derivation study but lacked robustness with wide CIs because of a small sample size and number of events observed. However, the CSRS did not miss any clinically relevant outcomes in low risk patients making it potentially useful in aiding their disposition. Larger validation studies in Australia are encouraged to further test the diagnostic accuracy of the CSRS.
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Affiliation(s)
- Jason Chan
- Emergency Department, Redcliffe Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Emma Ballard
- Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - David Brain
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Julia Hocking
- Griffith University, Brisbane, Queensland, Australia
| | - Alan Yan
- Emergency Department, Redcliffe Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Douglas Morel
- Emergency Department, Redcliffe Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jonathan Hunter
- Emergency Department, Redcliffe Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Solbiati M, Talerico G, Villa P, Dipaola F, Furlan R, Furlan L, Fiorelli EM, Rabajoli F, Casagranda I, Cazzola K, Ramuscello S, Vicenzi A, Casazza G, Costantino G. Multicentre external validation of the Canadian Syncope Risk Score to predict adverse events and comparison with clinical judgement. Emerg Med J 2021; 38:701-706. [PMID: 34039646 DOI: 10.1136/emermed-2020-210579] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 05/17/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The Canadian Syncope Risk Score (CSRS) has been proposed for syncope risk stratification in the emergency department (ED). The aim of this study is to perform an external multicenter validation of the CSRS and to compare it with clinical judgement. METHODS Using patients previously included in the SyMoNE database, we enrolled subjects older than 18 years who presented reporting syncope at the ED. For each patient, we estimated the CSRS and recorded the physician judgement on the patients' risk of adverse events. We performed a 30-day follow-up. RESULTS From 1 September 2015 to 28 February 2017, we enrolled 345 patients; the median age was 71 years (IQR 51-81), 174 (50%) were men and 29% were hospitalised. Serious adverse events occurred in 43 (12%) of the patients within 30 days. The area under the curve of the CSRS and clinical judgement was 0.75 (95% CI 0.68 to 0.81) and 0.68 (95% CI 0.61 to 0.74), respectively. The risk of adverse events of patients at low risk according to the CSRS and clinical judgement was 6.7% and 2%, with a sensitivity of 70% (95% CI 54% to 83%) and 95% (95% CI 84% to 99%), respectively. CONCLUSION This study represents the first validation analysis of CSRS outside Canada. The overall predictive accuracy of the CSRS is similar to the clinical judgement. However, patients at low risk according to clinical judgement had a lower incidence of adverse events as compared with patients at low risk according to the CSRS. Further studies showing that the adoption of the CSRS improve patients' outcomes is warranted before its widespread implementation.
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Affiliation(s)
- Monica Solbiati
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.,Dipartimento di Scienze Cliniche e di Comunita, Universita degli Studi di Milano, Milano, Italy
| | | | - Paolo Villa
- UOC Medicina d'Urgenza e Pronto Soccorso, Ospedale Luigi Sacco, Milano, Italy
| | - Franca Dipaola
- Department of Biomedical Sciences, Humanitas University IRCCS- Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University IRCCS- Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Ludovico Furlan
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | | | | | | | | | - Andrea Vicenzi
- UOC Medicina d'Urgenza e Pronto Soccorso, Ospedale Luigi Sacco, Milano, Italy
| | | | - Giorgio Costantino
- Dipartimento di Scienze Cliniche e di Comunita, Universita degli Studi di Milano, Milano, Italy .,UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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A Rational Evaluation of the Syncope Patient: Optimizing the Emergency Department Visit. ACTA ACUST UNITED AC 2021; 57:medicina57060514. [PMID: 34064050 PMCID: PMC8224075 DOI: 10.3390/medicina57060514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 12/13/2022]
Abstract
Syncope accounts for up to 2% of emergency department visits and results in the hospitalization of 12–86% of patients. There is often a low diagnostic yield, with up to 50% of hospitalized patients being discharged with no clear diagnosis. We will outline a structured approach to the syncope patient in the emergency department, highlighting the evidence supporting the role of clinical judgement and the initial electrocardiogram (ECG) in making the preliminary diagnosis and in safely identifying the patients at low risk of short- and long-term adverse events or admitting the patient if likely to benefit from urgent intervention. Clinical decision tools and additional testing may aid in further stratifying patients and may guide disposition. While hospital admission does not seem to offer additional mortality benefit, the efficient utilization of outpatient testing may provide similar diagnostic yield, preventing unnecessary hospitalizations.
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Sweanor RAL, Redelmeier RJ, Simel DL, Albassam OT, Shadowitz S, Etchells EE. Multivariable risk scores for predicting short-term outcomes for emergency department patients with unexplained syncope: A systematic review. Acad Emerg Med 2021; 28:502-510. [PMID: 33382159 DOI: 10.1111/acem.14203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Emergency department (ED) patients with unexplained syncope are at risk of experiencing an adverse event within 30 days. Our objective was to systematically review the accuracy of multivariate risk stratification scores for identifying adult syncope patients at high and low risk of an adverse event over the next 30 days. METHODS We conducted a systematic review of electronic databases (MEDLINE, Cochrane, Embase, and CINAHL) from database creation until May 2020. We sought studies evaluating prediction scores of adults presenting to an ED with syncope. We included studies that followed patients for up to 30 days to identify adverse events such as death, myocardial infarction, stroke, or cardiac surgery. We only included studies with a blinded comparison between baseline clinical features and adverse events. We calculated likelihood ratios and confidence intervals (CIs). RESULTS We screened 13,788 abstracts. We included 17 studies evaluating nine risk stratification scores on 24,234 patient visits, where 7.5% (95% CI = 5.3% to 10%) experienced an adverse event. A Canadian Syncope Risk Score (CSRS) of 4 or more was associated with a high likelihood of an adverse event (LRscore≥4 = 11, 95% CI = 8.9 to 14). A CSRS of 0 or less (LRscore≤0 = 0.10, 95% CI = 0.07 to 0.20) was associated with a low likelihood of an adverse event. Other risk scores were not validated on an independent sample, had low positive likelihood ratios for identifying patients at high risk, or had high negative likelihood ratios for identifying patients at low risk. CONCLUSION Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The CSRS is an accurate validated prediction score for ED patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost, or outcomes of care is not known.
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Affiliation(s)
| | - Robert J. Redelmeier
- Department of Medicine University of Toronto Toronto Ontario Canada
- Department of Medicine Sunnybrook Health Science Centre University of Toronto Toronto Ontario Canada
| | - David L. Simel
- Division of General Internal Medicine Duke Veterans Affairs Medical Center Durham North Carolina USA
- Duke University Durham North Carolina USA
| | - Omar T. Albassam
- Department of Medicine University of Toronto Toronto Ontario Canada
- Department of Medicine Sunnybrook Health Science Centre University of Toronto Toronto Ontario Canada
- Division of Cardiology King Abdulaziz University HospitalKing Abdulaziz University Jeddah Saudi Arabia
| | - Steven Shadowitz
- Department of Medicine University of Toronto Toronto Ontario Canada
- Department of Medicine Sunnybrook Health Science Centre University of Toronto Toronto Ontario Canada
| | - Edward E. Etchells
- Department of Medicine University of Toronto Toronto Ontario Canada
- Department of Medicine Sunnybrook Health Science Centre University of Toronto Toronto Ontario Canada
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Dipaola F, Shiffer D, Gatti M, Menè R, Solbiati M, Furlan R. Machine Learning and Syncope Management in the ED: The Future Is Coming. ACTA ACUST UNITED AC 2021; 57:medicina57040351. [PMID: 33917508 PMCID: PMC8067452 DOI: 10.3390/medicina57040351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 11/16/2022]
Abstract
In recent years, machine learning (ML) has been promisingly applied in many fields of clinical medicine, both for diagnosis and prognosis prediction. Aims of this narrative review were to summarize the basic concepts of ML applied to clinical medicine and explore its main applications in the emergency department (ED) setting, with a particular focus on syncope management. Through an extensive literature search in PubMed and Embase, we found increasing evidence suggesting that the use of ML algorithms can improve ED triage, diagnosis, and risk stratification of many diseases. However, the lacks of external validation and reliable diagnostic standards currently limit their implementation in clinical practice. Syncope represents a challenging problem for the emergency physician both because its diagnosis is not supported by specific tests and the available prognostic tools proved to be inefficient. ML algorithms have the potential to overcome these limitations and, in the future, they could support the clinician in managing syncope patients more efficiently. However, at present only few studies have addressed this issue, albeit with encouraging results.
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Affiliation(s)
- Franca Dipaola
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.S.); (R.F.)
- Internal Medicine, Humanitas Clinical and Research Center—IRCCS, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-0282247266
| | - Dana Shiffer
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.S.); (R.F.)
| | - Mauro Gatti
- IBM, Active Intelligence Center, 40121 Bologna, Italy;
| | - Roberto Menè
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy;
| | - Monica Solbiati
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, 20122 Milan, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.S.); (R.F.)
- Internal Medicine, Humanitas Clinical and Research Center—IRCCS, Rozzano, 20089 Milan, Italy
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A qualitative study to identify factors that influence patients' decisions to call Emergency Medical Services for syncope. CAN J EMERG MED 2021; 23:195-205. [PMID: 33709359 DOI: 10.1007/s43678-020-00045-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/14/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Protocols that support paramedics to assess, treat and refer low-risk syncope (fainting) may allow for ED transport of only high-risk patients. The development and uptake of such protocols is limited by a dearth of information about factors patients consider when deciding to seek EMS care following syncope. OBJECTIVE We explored decision-making processes of individuals with syncope regarding whether (or not) to call EMS after fainting as a starting point in the development of prehospital risk-stratification protocols for syncope. METHODS Twenty-five Canadian adults (aged 18-65 years) with a history of ≥ 1 syncopal episode were recruited. Individual semi-structured interviews were conducted, recorded, and transcribed. Straussian grounded theory methods were used to identify common themes and a core (overarching) category. RESULTS Four themes were identified: (a) previous experiences with the healthcare system (e.g., feeling dismissed), (b) individual patient factors (e.g., age, medical history), (c) attitudes and beliefs (e.g., burdening the health care system, syncope is "not serious"), and (d) contextual factors (e.g., influence of important others, symptom severity). Perceived judgement, including judgement from EMS and negative self-evaluations, was identified as the core category that influenced patients' decisions to seek care. CONCLUSION We theorize that, while patients consider many factors in deciding to contact EMS for syncope, previous experiences of feeling judged and unfavorable beliefs about syncope may interfere with patients' receptiveness to traditional EMS protocols for syncope. The findings highlight potential patient needs that program developers may wish to consider in the development of prehospital protocols to improve care and satisfaction among patients with syncope.
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Rosenberg H, Nath A, Thiruganasambandamoorthy V. Just the facts: how to assess a patient presenting to the emergency department with syncope. CAN J EMERG MED 2021; 23:286-290. [PMID: 33689119 DOI: 10.1007/s43678-021-00095-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/29/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Hans Rosenberg
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Hospital, Ottawa, ON, Canada.
| | - Avik Nath
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Calder LA, Perry J, Yan JW, De Gorter R, Sivilotti MLA, Eagles D, Myslik F, Borgundvaag B, Émond M, McRae AD, Taljaard M, Thiruganasambandamoorthy V, Cheng W, Forster AJ, Stiell IG. Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study. Ann Emerg Med 2021; 77:561-574. [PMID: 33612283 DOI: 10.1016/j.annemergmed.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope. METHODS This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes. RESULTS Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses. CONCLUSION Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.
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Affiliation(s)
- Lisa A Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Ria De Gorter
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marcel Émond
- Département de médecine Familiale et d'Urgence, Université Laval, Québec City, Quebec, Canada
| | - Andrew D McRae
- Departments of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan J Forster
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Thiruganasambandamoorthy V, Sivilotti MLA. Web Exclusive. Annals for Hospitalists Inpatient Notes - Identifying High-Risk Patients With Syncope-What Hospitalists Need to Know. Ann Intern Med 2021; 174:HO2-HO3. [PMID: 33587884 DOI: 10.7326/m20-8081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Zimmermann T, du Fay de Lavallaz J, Walter JE, Strebel I, Nestelberger T, Joray L, Badertscher P, Flores D, Widmer V, Geigy N, Miro O, Salgado E, Christ M, Cullen L, Than M, Martín-Sánchez FJ, Di Somma S, Peacock WF, Keller D, Costabel JP, Wussler DN, Kawecki D, Lohrmann J, Gualandro DM, Kuehne M, Reichlin T, Sun B, Mueller C. Development of an electrocardiogram-based risk calculator for a cardiac cause of syncope. Heart 2021; 107:1796-1804. [PMID: 33504514 DOI: 10.1136/heartjnl-2020-318430] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/31/2020] [Accepted: 01/03/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To develop an ECG-based tool for rapid risk assessment of a cardiac cause of syncope in patients ≥40 years. METHODS In a prospective international multicentre study, 2007 patients ≥40 years presenting with syncope were recruited in the emergency department (ED) of participating centres ranging from large university hospitals to smaller rural hospitals in eight countries from May 2010 to July 2017. 12-Lead ECG recordings were obtained at ED presentation following the syncopal event. The primary diagnostic outcome, a cardiac cause of syncope, was centrally adjudicated by two independent cardiologists using all available clinical information including 12-month follow-up. ECG predictors for a cardiac cause of syncope were identified using penalised backward selection and a continuous-scale likelihood was calculated based on regression analysis coefficients. Findings were validated in an independent US multicentre cohort including 2269 patients. RESULTS In the derivation cohort, a cardiac cause of syncope was adjudicated in 267 patients (16%). Seven ECG criteria were identified as predictors for this outcome: heart rate and QTc-interval (continuous predictors), rhythm, atrioventricular block, ST-segment depression, bundle branch block and ventricular extrasystole/non-sustained ventricular tachycardia (categorical predictors). Diagnostic accuracy of these combined predictors for a cardiac cause of syncope was high (area under the curve 0.80, 95% CI 0.77 to 0.83). Overall, 138 patients (8%) were rapidly triaged towards rule-out and 181 patients (11%) towards rule-in of a cardiac cause of syncope. External validation showed similar performance. CONCLUSION In patients ≥40 years with a syncopal event, a combination of seven ECG criteria enabled rapid assessment of the likelihood that syncope was due to a cardiac cause. TRIAL REGISTRATION NUMBER NCT01548352 (BASEL IX), NCT01802398 (SRS study).
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Affiliation(s)
- Tobias Zimmermann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Joan Elias Walter
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Ivo Strebel
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Thomas Nestelberger
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Lydia Joray
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Patrick Badertscher
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Dayana Flores
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Velina Widmer
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Nicolas Geigy
- Emergency Department, Kantonsspital Baselland, Liestal, Switzerland
| | - Oscar Miro
- GREAT network, Rome, Italy.,Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | - Michael Christ
- Emergency Department, Kantonsspital Luzern, Luzern, Switzerland
| | - Louise Cullen
- GREAT network, Rome, Italy.,Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Martin Than
- GREAT network, Rome, Italy.,Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | | | - Salvatore Di Somma
- GREAT network, Rome, Italy.,Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, University Sapienza Rome, Sant'Andrea Hospital, Rome, Italy
| | - W Frank Peacock
- GREAT network, Rome, Italy.,Emergency Department, Baylor College of Medicine, Houston, Texas, USA
| | - Dagmar Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | | | - Desiree Nadine Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy.,Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Damian Kawecki
- Department of Cardiology, Medical University of Silesia, Zabrze, Poland
| | - Jens Lohrmann
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Danielle Menosi Gualandro
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Michael Kuehne
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland.,GREAT network, Rome, Italy
| | - Tobias Reichlin
- GREAT network, Rome, Italy.,Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Benjamin Sun
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian Mueller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland .,GREAT network, Rome, Italy
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El-Hussein MT, Cuncannon A. Syncope in the Emergency Department: A Guide for Clinicians. J Emerg Nurs 2020; 47:342-351. [PMID: 33317859 DOI: 10.1016/j.jen.2020.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/11/2020] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
Syncope is a common presenting symptom to emergency departments, but its evaluation and initial management can be challenging for ED practitioners and particularly urgent in the presence of high-risk features that increase the likelihood of cardiac etiology. Even after thorough clinical evaluation, syncope may remain unexplained. In such instances, practitioners' clinical judgment and risk assessments are critical to guide further management. In this article, evidence-informed strategies are outlined to approach the diagnosis of syncope and provide an overview of syncope clinical decision rules and shared decision-making. By incorporating risk stratification and shared decision-making into syncope care, practitioners can more confidently engage patients and families in disposition decisions to organize appropriate outpatient and follow-up care, observation, or admission.
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